The Ultimate Care Group Limited - Ranburn

The Ultimate Care Group Limited - Ranburn

Introduction

This report records the results of a Surveillance Audit ofa provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).

The audit has been conducted byThe DAA Group Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.

The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).

You can view a full copy of the standards on the Ministry of Health’s website by clicking here.

The specifics of this audit included:

Legal entity:The Ultimate Care Group Limited

Premises audited:Ranburn Rest Home & Hospital

Services audited:Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)

Dates of audit:Start date: 2 February 2015End date: 3 February 2015

Proposed changes to current services (if any):None

Total beds occupied across all premises included in the audit on the first day of the audit:69

Executive summary of the audit

Introduction

This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:

• consumer rights
• organisational management
• continuum of service delivery (the provision of services)
• safe and appropriate environment
• restraint minimisation and safe practice
• infection prevention and control.

As well as auditors’ written summary, indicators are included that highlight the provider’s attainment against the standards in each of the outcome areas. The following table provides a key to how the indicators are arrived at.

Key to the indicators

Indicator / Description / Definition
Includes commendable elements above the required levels of performance / All standards applicable to this service fully attained with some standards exceeded
No short falls / Standards applicable to this service fully attained
Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity / Some standards applicable to this service partially attained and of low risk
A number of shortfalls that require specific action to address / Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk
Major shortfalls, significant action is needed to achieve the required levels of performance / Some standards applicable to this service unattained and of moderate or high risk

General overview of the audit

Ranburn Rest Home and Hospital provides residential care for up to 71 residents who require rest home, rest home dementia and hospital level care. The facility is operated by The Ultimate Care Group Limited.

This surveillance audit was conducted against the relevant Health and Disability Services Standards and the provider’s contract with the District Health Board. The audit process included review of the policies and procedures, review of residents and staff files, observations and interviews with residents, family, management, staff and a general practitioner.

This audit included a review of the eight aspects of service provision identified as requiring improvement from the previous certification audit, one of which has not been fully addressed and relates to resident documentation. There are areas requiring improvement from this audit relating to the currency of performance appraisals, the currency of competency assessments for restraint and aspects of safe food storage in the kitchen.

Consumer rights

Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. / Standards applicable to this service fully attained.

Staff demonstrated an understanding of residents' rights and obligations. This knowledge was incorporated into their daily work and caring for the residents. Information regarding resident rights, access to advocacy services and how to lodge a complaint is available to residents and their family and complaints are investigated. Staff communicate with residents and family members following any incident.

Organisational management

Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. / Some standards applicable to this service partially attained and of low risk.

The Ultimate Care Group Limited is the governing body and is responsible for the service provided at Ranburn Rest Home and Hospital (Ranburn). A ‘Management Plan’ and a ‘Quality and Risk Management Plan for Ranburn Lifecare’ was reviewed and included a vision statement, values, quality objectives, quality and risk management plan, quality indicators and quality projects. Systems are in place for monitoring the service provided at Ranburn that includes regular monthly reporting by the facility manager to The Ultimate Care Group Head Office. The facility is being managed by a facility manager who started in this role in August 2014 and is supported by a clinical services manager/registered nurse who is responsible for oversight of clinical care. The improvement required from the last audit relating to the facility manager position has been addressed.

The Ultimate Care Group quality and risk management systems are in place at Ranburn Rest Home and Hospital. There was evidence that quality improvement data is collected, collated, analysed to identify trends and corrective actions plans are developed and implemented. There is an internal audit programme, risks are identified, and there is a hazard register. Adverse events are documented on accident/incident forms and there is an electronic database reviewed by personnel from The Ultimate Care Group Head Office.

There are policies and procedures on human resources management. All health professionals had current practising certificates. In-service education is provided for staff at least monthly. Staff are also supported to complete the New Zealand Qualifications Authority Unit Standards through the Aged Care Education (ACE) programme. Not all clinical staff have current restraint competency assessments nor current performance appraisals.

Review of staff records provided evidence that human resources processes were followed and individual education records maintained.

There is a documented rationale for determining staffing levels and skill mix in order to provide safe service delivery, based on best practice. The minimum number of staff is provided during the night shift and consisted of one registered nurse and four caregivers. The facility manager, clinical services manager and the team leader are rostered on call after hours. All care staff interviewed reported there was adequate staff available and that they were able to get through their work. The improvement required from the last audit that related to the distribution of staff hours has been addressed.

Continuum of service delivery

Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. / Some standards applicable to this service partially attained and of low risk.

Five areas identified for improvement in the previous audit have all been fully attained by the service.

All residents’ files sighted from hospital, rest home and dementia care areas provide evidence that needs, goals and outcomes are identified and reviewed on a regular basis with the resident, and where appropriate their family/whanau. Resident and family/whanau members interviewed reported that they are satisfied with the services provided.

The assessment, provision of care and review of care is provided within timeframe to safely meet the needs of the residents. Improvements are required related to the documentation of evaluation of interventions at the time any changes are made. Services are coordinated in a manner that promotes a team approach and continuity of care. Care planning is based on assessment findings.

Planned activities provided reflect residents’ strengths, interests and level of ability across all three service streams.

Medicine management policies and procedures are implemented by staff and reflect safe medicine management practices.

The menu has been reviewed as meeting nutritional guidelines by a registered dietitian. Residents’ special dietary requirements and cultural needs are met. Interviews with residents verified a high level of satisfaction with meals. Freezer temperatures need to be maintained within safe food handling guidelines.

Safe and appropriate environment

Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. / Standards applicable to this service fully attained.

A current building warrant of fitness was displayed. Any maintenance issues are addressed and proactive maintenance carried out. Residents and family described the environment as meeting their needs.

Restraint minimisation and safe practice

Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. / Standards applicable to this service fully attained.

Policies and procedures implemented meet the requirements of the standards. There were 19 residents who use restraint and one resident who uses an enabler at the time of audit. The service maintains a process to determine approval for all types of restraint and enablers. The areas requiring improvement from the last audit relating to reducing the use of restraint, and holding approval group meetings has been addressed.

Infection prevention and control

Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme. / Standards applicable to this service fully attained.

Surveillance of infections is occurring according to the descriptions of the process in the programme. Data on the nature and frequency of identified infections is collated and results reported through all levels of the organisation, including governance.

Summary of attainment

The following table summarises the number of standards and criteria audited and the ratings they were awarded.

Attainment Rating / Continuous Improvement
(CI) / Fully Attained
(FA) / Partially Attained Negligible Risk
(PA Negligible) / Partially Attained Low Risk
(PA Low) / Partially Attained Moderate Risk
(PA Moderate) / Partially Attained High Risk
(PA High) / Partially Attained Critical Risk
(PA Critical)
Standards / 0 / 14 / 0 / 3 / 0 / 0 / 0
Criteria / 0 / 39 / 0 / 3 / 0 / 0 / 0
Attainment Rating / Unattained Negligible Risk
(UA Negligible) / Unattained Low Risk
(UA Low) / Unattained Moderate Risk
(UA Moderate) / Unattained High Risk
(UA High) / Unattained Critical Risk
(UA Critical)
Standards / 0 / 0 / 0 / 0 / 0
Criteria / 0 / 0 / 0 / 0 / 0

Attainment against the Health and Disability Services Standards

The following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit.

Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section.

For more information on the standards, please click here.

For more information on the different types of audits and what they cover please click here.

Standard with desired outcome / Attainment Rating / Audit Evidence
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The facility manager is responsible for the management of complaints and there are appropriate systems in place to manage the complaints processes. The complaints register reviewed included 13 internal complaints for 2014 and 2015.
The facility manager and chief clinical officer advised there had been a complaint to the District Health Board (DHB) since the last audit. Documentation reviewed indicates this complaint has been investigated by the provider and as a result improvements to service delivery have been implemented. The chief clinical officer interviewed advised this complaint had been closed out by the DHB. There have been no investigations by the Ministry of Health, Health and Disability Commissioner, Accident Compensation Corporation (ACC) or Coroner since the last audit.
Complaints policies and procedures are compliant with Right 10 of the Code. Systems are in place that ensure residents and their family are advised on entry to the facility of the complaint processes and the Code. Residents and family interviewed demonstrated an understanding and awareness of these processes. Resident meetings are held monthly and residents are able to raise any issues during these meetings. This was confirmed during interview of residents and family and review of resident meeting minutes. Review of the collated resident and family survey for November 2014 evidenced families were satisfied with the response they received as a result of making a complaint.
A visual inspection of the facility shows the complaint process readily accessible and displayed. Review of quality and staff meeting minutes and the facility manager’s reports provides evidence of reporting of complaints to the governing body and staff. Care staff interviewed confirm information is reported to them via their quality and staff meetings.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / FA / Policy reviewed identified that interpreter services are available to residents of Ranburn Rest Home and Hospital (Ranburn) and offered to residents with English as a second language.
Residents and family interviewed confirmed communication with staff is open and effective. Residents files reviewed evidenced residents were consulted and informed of any untoward event or change in care provision and included in care reviews. Residents and families responded very positively concerning effective communication from the resident and family survey collated in November 2014.
The service has an open disclosure policy which guides staff around the principles and practice of open disclosure. Education on open disclosure is provided at orientation and as part of the education programme. Staff interviewed confirmed their understanding of open disclosure. Communication with family is documented in the residents’ communication records. Incident forms evidenced families are informed when incidents occur.
Standard 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / FA / The Ultimate Care Group Limited (UCG) is the governing body and is responsible for the service provided at Ranburn. A ‘Business Plan 2015 – 2016’ and a 'Quality and Risk Management Plan’– January 2015 to January 2016’ for Ranburn were reviewed and include a vision statement, core values, quality objectives, quality indicators and quality projects, and scope of service. Also reviewed were documented values, mission statement and philosophy, which were displayed. The service philosophy is in an understandable form and was available to residents and their family / representative or other services involved in referring clients to the service.
The Ultimate Care Group has established systems in place which defined the scope, direction and goals of the organisation at UCG facilities, as well as the monitoring and reporting processes against these systems.
There is an 'Ultimate Care Group Clinical Advisory Group' (CAG) in place that includes two clinical services managers (CSMs), two regional managers, a facility manager, the chief clinical officer and clinical support advisor from UGC, who are responsible for reviewing clinical issues and policies and procedures following feedback from each of the UCG sites and from the governing body.
Meeting schedules and minutes reviewed provide evidence that monthly quality/staff/infection control, registered nurse (RN), and residents’ meetings are held. Meeting minutes are available for review by staff along with graphs of various clinical indicators. The facility manager (FM) provides weekly reports to the governing body. Reports include reporting on quality and risk management issues, occupancy, HR issues, quality improvements, internal audit outcomes, and clinical indicators.